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Three Part Question

IN [patients presenting with frozen shoulder]IS [exercise alone or exercise combined with manual therapy more effective] AT [reducing pain & improving function]

Clinical Scenario

A 50 year old woman is referred to physiotherapy with a diagnosis of frozen shoulder. There is a history of minor trauma. The pain is severe, & sleep disturbed. There is marked, global loss of range of movement actively & passively, especially external rotation.Serious pathgology has been excluded.Debate ensues as to the most effective way of improving pain & function in this patient group.

Search Strategy

AMED on DIAL DATASTAR interface 1985 - September 2008; CINHAL on DIAL Datastar interface 1950 - September 2008: Cochrane Library via National Library for Health.
MESH terms - Frozen shoulder OR patient education OR self care OR Exercise therapy AND Physical therapy AND massage AND reflex AND stretch AND tissue release AND accessory movements AND passive movements AND hydrotherapy AND manipulation And Chiropractic AND flexibility training AND hold relax.

Search Outcome

Altogether 27 papers were found, 1 of which was relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Diercks, R.L. et al 2004 Netherlands	Seventy seven patients with idiopathic frozen shoulder included in a prospective RCT comparing the effects of intensive physical rehabilitation including passive stretching & manual mobilisation (stretching group 1),up to & beyond pain threshold, versus supportive therapy & exercises within pain limits (supervised neglect group 2).All patients followed up for 24 months after starting treatment.	RCT	Constant score 3 monthly for 2 years	Group 2 shows Constant score change p<.001 in improvement which is sustained every three months, until at 24 moths p<.01.	Although ethically difficult to have a control group in the patient population, the intervention of supervised stretches at three monthly intervals makes it difficult to assess whether the improvement is due to addition of maintenance of range movement, or natural progression of the disease in Group 2. NSAId's were prescribed to both groups, the effects are not reported. Staging of the diease at inclusion is not clear.

Comment(s)

In this study, supervised neglect, ie encouraging stretch to within painless limits, & activity as tolerated is superior to stretching & exercising into painful ranges,yielding a better functional result in a shorter time scale. This comparative study is not representative of clinical practice,as the pathophysiology in the early stage of inflammation & proliferation would preclude therapists justifying such a treatment approach.

Clinical Bottom Line

Supervised neglect ie: stretches taught to maintain capsular flexibilty within the limits of pain, yields better results than stretch & manual therapy into painful ranges. This improvement continues for two years.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Diercks, R.L. Gentle thawing of the frozen shoulder: A prospective study of supervised neglect versus intensive physical therapy in seventy seven patients with frozen shoulder syndrome followed up for two years. Journal of Shoulder and Elbow Surgery March 2004, p499-502